The work performed by pilots is complex and involves considerable risks. Some of these risks are inherent to pilots embarking on and disembarking from vessels. Since these operations are performed in daylight or darkness and/or in difficult conditions such as rough and icy water, it is essential that pilot boat and vessel crews work together. All crew members involved in these operations are responsible for the location of devices designed to ensure the safety of the operation and to minimize the risk of accident, since recovering a person overboard is a difficult and risky operation for everyone. Wearing a PFD improves survival chances for pilots and rescuers, in the event of a man overboard. By wearing a PFD, the person overboard can be located in daylight or in darkness, and the effects of hypothermia are reduced until he or she is retrieved. The PFD is also fitted with a harness for hoisting the person aboard. As man overboard rescue and recovery operations are known to be difficult and risky, seamen who are exposed to such risks must be prepared to wear a PFD to improve their chances of survival in the water. The LPA is of the view that its responsibility to pilots is limited to transporting pilots to and from their assignments. As soon as the pilot steps onto the pilot ladder, that responsibility ends. And yet, the most critical periods of a pilot's assignment are embarkation and disembarkation. The LPA encourages pilots to wear a PFD, but currently it is not a requirement under the terms of the contractual agreement between the LPA and pilot corporations. The LPA considers that, since pilots are self-employed, they are not subject to the Canada Labour Code and the requirements of the Commission de la sant et de la scurit du travail du Qubec (CSST).4 Consequently, pilots cannot be required to wear a PFD. Although most pilots in the Laurentian region wear a PFD, some do not, and they run the risk of being involved in an occurrence like the one at issue. Life jackets are available on the Charlevoix, but pilots do not like wearing them because they are cumbersome. Even though PFDs are optional for pilots, they must accept responsibility for their decisions and avoid endangering, through their decisions, the lives of those who help them do their job. As required by the Standards for Pilot Vessels, the Charlevoixshould have had PFDs on board for all occupants; it was not in compliance with that requirement at the time of the occurrence. A malfunction of the bridge control system can create a safety hazard when coming alongside for embarkation or disembarkation. Embarkation and disembarkation must take place quickly, is sometimes carried out in harsh weather and sea conditions, and/or in daylight or darkness, and often involves only one person. Executing the coming alongside manoeuvre from the bridge requires a very steady hand and considerable skill. The task is even more delicate if the person being hoisted aboard is unconscious. Such occurrences generate a great deal of interest and concern among pilotage authorities. The EMPA approved the following recommendations to enhance awareness of pilots employed by European pilotage authorities:5 the importance of wearing a PFD while in transit to assignments; the role that pilots can play by encouraging colleagues to wear a PFD and making them realize that they should wear one while embarking and disembarking; and the importance of encouraging pilots to take part in practice drills in using recovery devices on pilot boats. The International Maritime Pilots' Association (IMPA), under the International Maritime Organization (IMO), has no international equivalency system with respect to pilots wearing PFDs and to awareness of recovery devices available for assisting pilots in an emergency.Analysis The work performed by pilots is complex and involves considerable risks. Some of these risks are inherent to pilots embarking on and disembarking from vessels. Since these operations are performed in daylight or darkness and/or in difficult conditions such as rough and icy water, it is essential that pilot boat and vessel crews work together. All crew members involved in these operations are responsible for the location of devices designed to ensure the safety of the operation and to minimize the risk of accident, since recovering a person overboard is a difficult and risky operation for everyone. Wearing a PFD improves survival chances for pilots and rescuers, in the event of a man overboard. By wearing a PFD, the person overboard can be located in daylight or in darkness, and the effects of hypothermia are reduced until he or she is retrieved. The PFD is also fitted with a harness for hoisting the person aboard. As man overboard rescue and recovery operations are known to be difficult and risky, seamen who are exposed to such risks must be prepared to wear a PFD to improve their chances of survival in the water. The LPA is of the view that its responsibility to pilots is limited to transporting pilots to and from their assignments. As soon as the pilot steps onto the pilot ladder, that responsibility ends. And yet, the most critical periods of a pilot's assignment are embarkation and disembarkation. The LPA encourages pilots to wear a PFD, but currently it is not a requirement under the terms of the contractual agreement between the LPA and pilot corporations. The LPA considers that, since pilots are self-employed, they are not subject to the Canada Labour Code and the requirements of the Commission de la sant et de la scurit du travail du Qubec (CSST).4 Consequently, pilots cannot be required to wear a PFD. Although most pilots in the Laurentian region wear a PFD, some do not, and they run the risk of being involved in an occurrence like the one at issue. Life jackets are available on the Charlevoix, but pilots do not like wearing them because they are cumbersome. Even though PFDs are optional for pilots, they must accept responsibility for their decisions and avoid endangering, through their decisions, the lives of those who help them do their job. As required by the Standards for Pilot Vessels, the Charlevoixshould have had PFDs on board for all occupants; it was not in compliance with that requirement at the time of the occurrence. A malfunction of the bridge control system can create a safety hazard when coming alongside for embarkation or disembarkation. Embarkation and disembarkation must take place quickly, is sometimes carried out in harsh weather and sea conditions, and/or in daylight or darkness, and often involves only one person. Executing the coming alongside manoeuvre from the bridge requires a very steady hand and considerable skill. The task is even more delicate if the person being hoisted aboard is unconscious. Such occurrences generate a great deal of interest and concern among pilotage authorities. The EMPA approved the following recommendations to enhance awareness of pilots employed by European pilotage authorities:5 the importance of wearing a PFD while in transit to assignments; the role that pilots can play by encouraging colleagues to wear a PFD and making them realize that they should wear one while embarking and disembarking; and the importance of encouraging pilots to take part in practice drills in using recovery devices on pilot boats. The International Maritime Pilots' Association (IMPA), under the International Maritime Organization (IMO), has no international equivalency system with respect to pilots wearing PFDs and to awareness of recovery devices available for assisting pilots in an emergency. The pilot lost his footing when starting down the ladder to the pilot boat Charlevoix. The pilot fell about three metres into the water, and he was not wearing a personal flotation device (PFD) at the time of the occurrence. The pilot spent about eight minutes in the water, at an estimated temperature of 2C. The investigation revealed that the crew and pilot were not properly trained in the use of the recovery device; such training is essential to maximize chances of survival. The recovery device was not permanently installed to allow rapid deployment in an emergency. Practice drills in man overboard recovery are not part of a regular training program on the Charlevoix. There is no contractual agreement between the Laurentian Pilotage Authority (LPA) and pilot corporations requiring pilots to wear a PFD when on assignment. According to the LPA, its responsibility to pilots is limited to transporting pilots to and from their assignments, and as soon as the pilot steps onto the pilot ladder, that responsibility ends. The Charlevoix had mechanical problems when coming alongside the CanmarValour. The 12-volt dc power supply unit and the battery supplying power to the bridge control system failed at the same time, making the system unserviceable. The power supply system was in the shut-off position, and the power supply unit compartment was hot. The power supply unit compartment was equipped with a 10-cm fan, but there was no grille to allow air flow. The Standards for Pilot Vessels do not reflect the current reality regarding embarkation and disembarkation operations for marine pilots.Findings The pilot lost his footing when starting down the ladder to the pilot boat Charlevoix. The pilot fell about three metres into the water, and he was not wearing a personal flotation device (PFD) at the time of the occurrence. The pilot spent about eight minutes in the water, at an estimated temperature of 2C. The investigation revealed that the crew and pilot were not properly trained in the use of the recovery device; such training is essential to maximize chances of survival. The recovery device was not permanently installed to allow rapid deployment in an emergency. Practice drills in man overboard recovery are not part of a regular training program on the Charlevoix. There is no contractual agreement between the Laurentian Pilotage Authority (LPA) and pilot corporations requiring pilots to wear a PFD when on assignment. According to the LPA, its responsibility to pilots is limited to transporting pilots to and from their assignments, and as soon as the pilot steps onto the pilot ladder, that responsibility ends. The Charlevoix had mechanical problems when coming alongside the CanmarValour. The 12-volt dc power supply unit and the battery supplying power to the bridge control system failed at the same time, making the system unserviceable. The power supply system was in the shut-off position, and the power supply unit compartment was hot. The power supply unit compartment was equipped with a 10-cm fan, but there was no grille to allow air flow. The Standards for Pilot Vessels do not reflect the current reality regarding embarkation and disembarkation operations for marine pilots. The manoeuvre of coming alongside the CanmarValourwas hampered by mechanical problems on the Charlevoix. To reduce waiting time alongside the CanmarValour, the pilot started down the ladder with more than usual haste. In his hurry, reduced concentration may have affected the way he stepped onto the pilot ladder. He did not succeed in grasping the right bulwark stay and fell into the water. All members of the pilot boat crew and a pilot who was on board at that time took part in the recovery operation. The pilot was not wearing a personal flotation device and the pilot boat was having mechanical problems; this made the recovery more delicate. The lack of training and skill in the use of the recovery device did not make the operation any easier.Causes and Contributing Factors The manoeuvre of coming alongside the CanmarValourwas hampered by mechanical problems on the Charlevoix. To reduce waiting time alongside the CanmarValour, the pilot started down the ladder with more than usual haste. In his hurry, reduced concentration may have affected the way he stepped onto the pilot ladder. He did not succeed in grasping the right bulwark stay and fell into the water. All members of the pilot boat crew and a pilot who was on board at that time took part in the recovery operation. The pilot was not wearing a personal flotation device and the pilot boat was having mechanical problems; this made the recovery more delicate. The lack of training and skill in the use of the recovery device did not make the operation any easier. Further to this occurrence, the TSB forwarded Marine Safety Advisory (MSA) No05/00 to Transport Canada, emphasizing the need for pilots to wear a PFD when embarking and disembarking their assignment vessel, and the need for a review of current practices, policies, and requirements set out in the Standards for Pilot Vessels (TP 10531). To date, the situation is unchanged, as no action has been taken to require pilots to wear a PFD and the Standards for Pilot Vessels have not been amended.Safety Action Further to this occurrence, the TSB forwarded Marine Safety Advisory (MSA) No05/00 to Transport Canada, emphasizing the need for pilots to wear a PFD when embarking and disembarking their assignment vessel, and the need for a review of current practices, policies, and requirements set out in the Standards for Pilot Vessels (TP 10531). To date, the situation is unchanged, as no action has been taken to require pilots to wear a PFD and the Standards for Pilot Vessels have not been amended.